The Vancouver coroner’s office revealed that “Glee” star Cory Monteith died of a toxic mixture of alcohol and heroin, weeks after leaving rehab for substance misuse. His death highlights the dangers of the post-rehab period, and why patients are most vulnerable just after they receive treatment.

Monteith’s history of distress began early: in an interview with Parade, the 31-year old admitted that at 13, he drank and smoked marijuana and by 16, he had attended 12 different schools, including some described in the article as “alternative programs for troubled teens.”

And that’s where the “system” —the programs and facilities and treatment strategies most commonly called into action to help addicts — started to fail Monteith. The evidence suggests that many of these institutions are ineffective or even potentially harmful— “troubled teen” is not a standardized diagnosis and most of these largely unregulated residential centers do not effectively identify or treat the most common psychiatric issues that affect teens with behavior problems, including addictions. The programs certainly didn’t help Monteith, who dropped out and, by his own admission, only continued his drug use.

At 19, his mother and friends staged an intervention. Traditional interventions, which force the addict to either get help or face consequences such as prison, are half as effective as approaches that use more supportive methods of motivation, such as Community Reinforcement and Family Therapy (CRAFT), which focuses on building a social environment that reinforces sobriety and discourages drug use. While tough interventions are often used as a last resort, most families are not even aware of the less forceful approaches. And unfortunately, relapse is more common after such compulsory treatment.

Monteith relapsed almost immediately, admitting in Parade that “I did the stint but then went back to doing exactly what I left off doing.” Part of the problem may have been with the rehab program itself; research suggests that many programs don’t take advantage of available medications approved by the Food and Drug Administration (FDA), don’t provide talk therapy program that have been proven effective, and instead rely on punishing, boot-camp style intimidation tactics such as humiliating emotional attacks and re-enactments of trauma that are known to send teens back to drugs or make them even more rebellious.

Acting gave Monteith a purpose and goals— at least for a while, and helped to tame his addictions. But despite his enormous success as Finn Hudson on “Glee,” Monteith was lured back to drugs in the months before his death.

He did a second round of rehab, checking himself into a facility last April. While it’s not clear why he was receiving treatment, if, given the coroner’s report, he was seeking help for heroin addiction, a lack of tolerance may have contributed to his death. Heroin, an opioid, produces tolerance, so that users not only need more drug to experience a “high,” but also higher amounts to overdose. Abstaining for a few weeks, as many rehab programs require, lowers this tolerance so if an addict were to use again, a previously normal dose could become fatal. Most deadly overdoses occur either in new users or in experienced addicts following a period of abstinence, such as in prison or rehab. Indeed, the first two weeks after prison carry an overdose risk rate that is more than 120 times higher than typical among users, according to one study.

Which is why leading experts like the National Institute on Drug Abuse have long advocated for maintenance treatment with drugs like methadone or Suboxone to treat opioid addictions, rather than abstinence. Research shows that these treatments can lower overdose and disease-related death rates but they remain controversial, since most residential rehab facilities prefer the strategy of total abstinence from any medications, even therapeutic ones for addiction.

Only last year did Hazelden, which pioneered this abstinence approach with the “Minnesota Model,” on which 90% of American treatment is based, begin adding maintenance therapies. As I wrote then, Hazelden did so because too many people were dying in the first few months after leaving rehab, like Monteith. Abstinence was proving to be doubly harmful— addicts were turning back to their drugs of choice, and when they were, their lower tolerance was putting them in danger of overdosing. “[Those] deaths were certainly a major issue in our decision making,” Hazelden’s chief medical officer, Dr. Marvin Seppala, said.

Adding to the danger is the fact that, as in Monteith’s case, most overdoses do not involve just one class of drugs. Monteith combined alcohol with heroin — two drugs that depress breathing, which can be a recipe for death. About 60% of so-called opioid overdoses — overdoses blamed on painkillers or heroin— are actually the result of such combinations. While some addicts will intentionally take such mixtures to intensify the high, many are unaware of issues like tolerance or the dangers of combining drugs.

And there may be one last way in which Monteith’s death can serve as a lesson for how to serve addicts better. There is a safe and nontoxic antidote, naloxone, to treat opioid overdose, which I have argued should be available in first aid kits so more potential victims might be saved. Improving such rescue therapies, as well as those used in rehab treatment programs, could lead to fewer tragedies like Monteith’s death.

Drug addition is a real problem with a lot of people these days. Once one starts down the road of highly addictive drugs than you can have a real hard time getting off them... It often messes up a lot of people lives not just there own but those that are close to them... Thanks for the great article.... http://halitosistreatmentblog.wordpress.com/

Thank you for sharing your thoughts! Important thing to remember a person suffering from drug addition must help himself to get over to drugs. Well it is very important for a person who is suffering a drug addition to have the support of his/her family to get back to his normal life. we really have to address the growing number of drug addition to the world especially to the teenagers. Most cases of drug abuses are from teens and early adults. We mus help them cope up from grieving, depressions that may be a cause of addictions. Encourage them to be active on sports or other recreational activities. Its a good way of make them forget depressions. And to those who are suffering from addiction help them to be admit in a drug treatment center. There are experts that can help them and recover. http://soberliving.pw

No one can help you, but your self! This blog got a great topic which provide's a realization not just for drug addicted victim but also to their families. We must provide our full attention and care in order to healed. Thanks for a nice ad!

I think this is really superb article i am completely agree that system is not only responsible but society is equally responsible for these kind of activities and there should be much more awareness and much more re habitation campaign should need to be there.

My thoughts: The system failed Cory and is failing for others. It all comes down to the almighty dollar...business /budgets have become more important than human life.

I work at a hospital in BC and the cutbacks/staffing/resources have been lacking for years. Drug addiction happens to people of all colour,age and social status and is a disease...something no one wishes to have. In order for a patient to be successful, they need a team to support them.(Health/addictions program,counsel,meds if needed,treatment plan,follow up-family,friends and co-workers if working).

What I don't understand is why random drug testing is required by athletes, and other professions but not for celebrities? These tests are done as not to compromise the sport/reputation or the business and to be honest and true. Would the movie studios /SAG, record companies,not rather pay for drug testing and keep the celebs alive and making them money or is it worth more in dollars and cents otherwise?

As a part of the addiction treatment industry for 25 years, the article is correct in saying the industry failed him and his family. I would not agree in the articles way that he was failed. The criticism doesn't really matter; what matters is that hundreds of thousands of families are desperately looking for solutions and our field has offered little.

I think too many people are ascribing the behavior of an adult recovering addict to someone who started using long before he was 18, let alone 25, around when people actually finish maturing (brain-wise). I would be interested in any studies that examined the longitudinal effect of drugs on a person's neurochemistry when they began using these substances at the beginning of puberty. I'm not a scientist, but I wouldn't be surprised to learn that drug use in childhood affects a person's psychological addiction and decision making processes, compared to someone who became an addict in adulthood.

I have to agree he shouldn't have been left so soon after another session in rehab, a mentor should have been with him, especially if it was known how vulnerable he was each time he visited his hometown, another truly waste of a young life R.I.P Cory x

I feel he should not have been on his own. He needed a responsible mentor. He could not be trusted alone. Many people feel "grown up" and refuse assistance. Helping someone overcome addiction is a 24 hour job. I wish he was not left alone......

Not sure if you read these comments, but I wanted to say first of all, that I adore all of your writing on issues of drug use, harm reduction and treatment. I have one tiny bone to pick with this one, where you say in regards to naloxone that "the drug is currently only available in injectable form, which makes
it both difficult and dangerous for untrained people to administer"--but the majority of overdose prevention programs that distribute naloxone distribute the injectable form and have for the last 15+ years (although they are "trained"). There are of course a few programs that also provide intranasally administered naloxone (including ours) but most programs have successfully saved hundreds and in some cases thousands of lives using injectable naloxone. In fact, while there are benefits to the intranasal naloxone, most people actually find the injectable naloxone easier to administer since the nasal adapter is a bit of a pain to assemble. I know this is a minor point, but I would love for there not to be added misunderstandings about the safety and efficacy of naloxone distribution, whether it is injectable or nasal. And my apologies if I misunderstood your statement to begin with!

Thank you again for your incredible insights and commitment to these issues!

maia, thanks for this column! i've been in recovery for 23 years ... and i learned early that if i were to relapse, it wouldn't be like starting from the beginning but being off to the races right out of the gate, picking up right where i left off if not more so ...

Also, his stint in rehab in April was not long enough at all. Heroin addicts need 3 plus months in rehab, at the least. Something got him out early - whether it was him saying he was ready and serious to be drug free and everyone believed him or whether he was playing everyone and always intended to keep using - we'll never know. Where it comes to rehab facilities for the famous/ those with influence and money, staff need to be more forceful. There needs to be more care. They simply let him go way too early.

Addiction isn't a choice people. Yes, the initial action whereby he first tried drugs was a choice. However, he was a kid with issues. From there, he became an addict. Drugs get you addicted. They are addictive. Anyone who smokes knows how hard it is. I don't smoke but watched my dad smoke a pack a day until his massive stroke (which doctors told me there was a 98% chance he'd be brain damaged). He survived and got all of his mobility and speech back. He quit cigarettes cold turkey. Cigarettes nearly killed my father - I'm lucky to still have him around. I'm not saying cigarettes and drugs are comparable in terms of their level of addiction at all, but I'm saying once you start, it's very hard to stop. I believe Cory made the mistake of going back home without a support network. Clearly the fact that he was around friends who encouraged that environment, maybe even used themselves, and was in an area where the drugs were so free-flowing, is what made the temptation too great.

SLUGS they are sick, lonely, unable, guilt-ridden and shame-filled. They need SLUGS as well sobriety, love, unity, growth and spirituality. I wonder whether Cory has follow-up treatments for inpatient. He was out in Vancouver for that's where his family and friends live but sadly there are places in there where drugs are free-flowing in broad daylight! Sometimes, if we let it, we are easilt influenced by the environment around us.

Whether the article has the correct information or not, it is "TRUE." Roughing up a child who has already been roughed up at home or emotionally abused, which is where many of these young ones come from that have turned to drugs, is not effective! At that point the child feels "helpless." All the system or the parent did was put a person who was already in a bad situation, in a worse one!! - I found that one treatment center here in the US left a child having insulin reactions from his type 1 diabetes while locked in a room, for no bad behavior whatsoever. This can not only cause death, but if it doesn't it can cause long term brain damage. When you walked into the area where the kids stayed that were being evaluated for treatment (90 days), it smelled like urine so bad it was pathetic! The attendants were abusive and the place was disgusting!

What a poorly researched article with a self-serving headline. It all started in his teens when "the system" FAILED him.. after 12 schools, some of which were "alternative programs". The author couldn't even read a Parade article properly, which never gives any impression that those programs had anything to do with youth drug treatment, let alone the "boot camp" variety, which is virtually non-existent in Canada -- typical American bias! There is no evidence that Cory availed himself to any addictions treatment in his teens, other than what he received at age 19 after his family's intervention and then again at 31. And what does she know about those two programs he attended? Even if they treated and discharged him with meds, it was still up to him to take them.

boo hoo, the system failed a white guy who had money. the prison industry fails everyone arrested for drug charges and treats mental illness by making people with those issues criminals. celebrities go to posh rehabs and it's great pr. you live in the ghetto then you get nothing.

Let's blame it on everything but the addict!! Just like the rest of the celebrity addicts, it's not their fault. Yadda, yadda, yadda. If they don't take responsibility for their own behavior, they will have to have a "keeper" with them 24/7.

But Dr. Bertha Madras, deputy director of the White House Office on National Drug Control Policy, opposes the use of Narcan in overdose-rescue programs.

"First of all, I don't agree with giving an opioid antidote to non-medical professionals. That's No. 1," she says. "I just don't think that's good public health policy."

Madras says drug users aren't likely to be competent to deal with an overdose emergency. More importantly, she says, Narcan kits may actually encourage drug abusers to keep using heroin because they know overdosing isn't as likely.

Madras says the rescue programs might take away the drug user's motivation to get into detoxification and drug treatment.

"Sometimes having an overdose, being in an emergency room, having that contact with a health care professional is enough to make a person snap into the reality of the situation and snap into having someone give them services," Madras says.

I would agree that this article places blame on ¨the system," yet never mentions the choices that Corey Monteith made. His death tragic and my heart goes out to his family and friends. Regarding this article it seems to me that if a addict was taking a maintenance dose of methadone they then would be more likely to overdose if they used heroin not less likely because they would be combining two different opiates. Also, I find it hard to believe that any adult would not be aware that mixing alcohol and heroin is extremely dangerous. I think just about everyone realizes that heroin on its own is extremely dangerous. I think interventions that use punishements such as jail due so as a last resort to get addicts into treatment. Once there the patient can be given more gentle types of support, and their family can certainly get family therapy. I don´t see how threatening the addict with potential punishments prevents the treatment center from using family therapy or community support. Unless the addict agrees to get treatment those gentler approaches won´t do them any good.

the system didn't "fail" him. he rejected it. you can only do so much for a person before it comes down to their personal choices and decisions. the system could be perfect, but if a junkie wants his fix, he's going to get it. instead of blaming the system or others, why don't we put a bit more emphasis on personal responsibility and holding people accountable for their actions?

Surprising that any rehab program would consider 30 days adequate for a narcotic addiction, particularly with no maintennace treatment and therapy component. Narcotics are physically addictive as well as psychologically. Most would say 6 month minimum in a clean house.One size certainly does not fit all but that would be a drop in a bucket for someone using regualrly.

@gofish This is a good point. I live in Victoria, BC, Canada, and the alternative schools for troubled teens that are here are the opposite of boot camp -- perhaps they are too lenient, but that is a different matter. However, I also wonder about the 100% sobriety model of addiction treatment, and would like to see more options accepted. Addicts are shamed by their addiction and by society -- when 100% sobriety works, it looks great, but doesn't the idea that it is the only way increase the shame for those who don't make it?

@swagger Absolutely -- except that we should be writing and caring as much about every single person on the street with mental health and/or addiction problems...... perhaps the shock or the death of someone who had "everything" can shock us into realizing how hard it is to live in our society, caring, perhaps understanding or changing ourselves

@paul.armentano "Narcan kits may actually encourage drug abusers to keep using" is nothing more and nothing less than an extension of the wrong-headed arguments against teaching age-appropriate sex ed in schools. Both are lies.

@Jeff7979 Regardless of what type of treatment, the recidivism rate is very, very high. It's close to 90%. I do agree that personal responsibility must be a factor. In any good program, it is. I'm not sure that jail is an answer, as it actually makes it more likely that the person will relapse.

@cjh2nd Cory got addicted when he was 13. With heroin, if you're addicted, it's not really a choice. When you first START using it, it's a choice. But one month of rehab is not going to cure a heroin addict. That's just not possible. It's one of the most addictive substances on the planet.

He should have been in rehab longer. At least a year, and then he shouldn't have been allowed to be alone, for his own safety.

But we can save a lot more people just by having our voices heard and telling our government to make the cops do their jobs and go after the drug dealers. Then maybe young kids wouldn't get hooked on them.

you can't force someone to be sober if they don't want to be. he clearly didn't want to be. he knew the risks and he messed up. it's sad and unfortunate but he made a choice. it turned out to be a poor one, but he made it. he was a grown-ass man. he knew the risks and didn't care

Exactly! I was even shocked that he just underwent rehab for like 30 days when he was struggling half of his life. Addiction is a complex matter that it should be treated with the right things possible. You also need support from your family. "Addicts are SLUGS

@Jeff7979@Smiling1809 Honestly, as a counselor and LCDC in training, my opinion is that you can't help people who don't want to help themselves. You can't force recovery. I know for me, I had to be ready to give up alcohol. I tried a couple times b/c of my husband, and failed. But, one day, something clicked and I was ready. There has been no looking back.

@rpearlston@Smiling1809@Jeff7979 I am very aware of the neurochemical aspect of addiction (I am almost done with my LCDC and am a counselor, and a recovering alcoholic.) But, personal responsibility is still a part of it. You have to wake up everyday determined not to slip. You have to actively fight the urges. You have to get help if you feel like you are going to slip. People must play an active part in their own recovery. I do understand, however, the difficulty due to changes in the brain. Many people are never the same again, ever. They felt so amazing on their drug of choice that they don't feel alive and happy unless they are high. This is one of the reasons recidivism is so high. recovery is so complicated. It isn't just about willpower.